基于临床决策支持的电子护理病历后馈控制系统的建立及效果评价

Establishment and effect evaluation of electronic nursing record feedback control system based on clinical decision support

目的:建立基于临床决策支持系统(CDSS)的电子护理病历后馈控制系统并进行效果评价。方法:2023年1月,南京大学医学院附属鼓楼医院启动CDSS建设项目,成立电子护理病历小组,通过文献查阅、访谈后提供建立CDSS所需的信息资料和建设思路,软件工程师开发CDSS电子护理病历后馈控制系统。随机选取南京大学医学院附属鼓楼医院的16个病区,对传统护理质控和基于CDSS的电子护理病历后馈控制系统的质控效果进行比较。采用随机数字表的方法,将16个病区分为试验组(n=8)和对照组(n=8)。试验组对出院病历采用信息化后馈控制系统进行质控;对照组对于出院病历采取传统的人工核查方法进行质检,分析两组质控系统的质控时长和发现问题的能力。结果:试验组的质控时长为(2.00±0.66)min,低于对照组的(6.20±1.54)min,差异有统计学意义(P<0.05)。试验组核查出的护理量表评估记录单、护理会诊记录单、护理记录单、体温单、护理培训及质控记录单、出院记录单以及发现的问题总数量均高于对照组,差异有统计学意义(P<0.05)。试验组的电子护理病历后馈控制系统满意度高于对照组的传统人工核查,差异有统计学意义(P<0.05)。结论:基于CDSS的电子护理病历后馈控制系统的建立,有利于提高电子护理病历质量,缩短出院病历质控时长,提高用户使用满意度,值得在临床应用。

Objective An electronic nursing medical record feedback control system based on clinical decision support system(CDSS)was established and the effect was evaluated.Methods In January 2023,the CDSS construction project was initiated at the Drum Tower Hospital Affiliated to Nanjing Medical University.A nursing team for electronic health records was established to provide information and construction ideas required for the establishment of CDSS through literature review and interviews.Software engineers developed the CDSS electronic nursing record feedback control system.Sixteen wards at the Drum Tower Hospital affiliated to Nanjing Medical University were randomly selected to compare the quality control effects of traditional nursing and CDSS-based electronic nursing record feedback control systems.Using a random number table,the 16 wards were divided into an experimental group(n=8)and a control group(n=8).The experimental group used an informationized feedback control system for discharge records,while the control group employed traditional manual inspection methods for quality control.The duration of quality control and the ability to detect problems between the two quality control systems were analyzed.Results The quality control duration in the experimental group was(2.00±0.66)minutes,which was lower than that of the control group(6.20±1.54)minutes,with statistically significant differences(P<0.05).The number of nursing assessment record sheets,nursing consultation record sheets,nursing record sheets,temperature charts,nursing training and quality control record sheets,discharge record sheets,and total number of problems discovered in the experimental group were higher than those in the control group,with statistically significant differences(P<0.05).The satisfaction with the electronic nursing record feedback control system in the experimental group was higher than that of the traditional manual inspection in the control group,with statistically significant differences(P<0.05).Conclusions The establishment of an electronic nursing record feedback control system based on CDSS is beneficial for improving the quality of electronic nursing records,reducing the duration of discharge record quality control,enhancing user satisfaction,and is worthy of clinical application.